Please fill out the below patient registration form or download a copy here and bring it with you to your first appointment.


    Patient Details

    Title

    First Name

    Last Name

    Date of Birth


    Address

    Suburb

    State

    Postcode


    Email Address

    Mobile Phone

    Home Phone

    Work Phone


    Medicare Details

    Medicare Number

    Ref Number next to name

    Expiry Date


    Parent/Carer Details If Patient is a Minor

    First Name

    Last Name

    Date of Birth

    Medicare Number


    Next of Kin/Emergency Contact

    Name

    Relationship

    Contact Number


    Private Health Fund Details

    Level of Cover

    Private Health Fund Name

    Private Health Fund Membership Number


    Dept of Veterans Affairs Details

    DVA Card

    DVA Card Number

    DVA White Card Approved Condition


    Referring Doctor Details

    Referring Doctor’s Name

    Clinic Suburb

    GP Name (if not referrer)

    Clinic Suburb


    SMS Appointment Reminder

    Do you wish to receive appointment reminders via SMS?


    Privacy Information

    To enable the ongoing provision of care within this practice, and in keeping with the Privacy Act 1988 and Australian Privacy Principles (APPs), we wish to provide you with information on how your personal and health information may be used or disclosed.

    WestsideENT collects information from you for the primary purpose of providing quality health care. We require you to provide us with your personal details and full medical history so that we may properly assess, diagnose, treat and be proactive in your health care needs.

    Your personal and health information will only be used for the purposes for which it is collected, or as otherwise permitted by law.


    Consent

    I have read the information above and understand the reasons why my information must be collected. I am also aware that WestsideENT has a Privacy Policy on handling patient information which is displayed on its website.

    I consent to the use of my personal and health information by WestsideENT and other health providers involved in my medical care. I consent to the disclosure of my personal and health information by WestsideENT to other health providers directly or indirectly involved in my personal health care or medical treatment.

    I give my consent to WestsideENT to contact medical practitioners or other bodies I have consulted to obtain health and other information that may be pertinent to my care. I authorise those medical practitioners or bodies to release such information, which may include sensitive health information, to WestsideENT as may be requested.



    Medical Information

    Medical Conditions (Please tick all that apply)
    High Blood Pressure
    Cardiac Bypass Surgery
    Blood Clots / Pulmonary Embolism / DVT
    Chronic lung disease/COPD
    Stroke
    Cardiac Stents
    Asthma
    Atrial Fibrillation
    Heart Attack
    TIA
    Diabetes


    Bleeding Disorders

    Do you have a history of any bleeding diseases?

    Is there a family history of any bleeding diseases?


    Do you take any of these medications?

    Aspirin
    Eliquis (apixaban)
    Anti-inflammatory drugs
    eg neurofen, brufen, celebrex, voltaren
    Pradaxa(dabigatran)
    Plavix (clopidogrel)
    Warfarin
    Xarelto (riviroxaban)


    Current Medications


    Allergies



    Smoking & Alcohol History

    Smoking Status

    No of years smoking

    No of cigarette per day

    Quit Date


    Do you drink alcohol?

    Drinks per week

    Your Signature



    BOOK AN APPOINTMENT

    Call us at 07 3202 4636

    or